Jun 01, 2020
By Asmaa Mabrouk

Trauma-informed care for survivors of human trafficking: An NP-led initiative

iStock.com/KatarzynaBialasiewicz

Take away messages:

  • As front-line health-care providers it is important that nurses recognize the prevalence and importance of trauma in our patients’ lives and our role in supporting them through it.
  • Survivors of human trafficking deserve and have a right to the same judgment-free, high quality, and compassionate care as any other patient.
  • Trauma-informed care should be a routine practice for every health-care provider, regardless of the setting they work in or the population they see!

As nursing students, we learn a lot about patients. We learn to consider culture, age, religion, and gender when interacting with them. We learn to watch for poor capillary refill, dilated pupils, and elevated blood pressure. We learn to look at the person as a whole, not just as a set of symptoms and a list of medications to memorize, study, and regurgitate on demand.

However, despite all this focus on considering the person as a whole, the first time I heard the words “human trafficking” in relation to health care, I was one year into my nursing studies at university, and it was at Ottawa’s H.E.A.L.T.H. Clinic.

In Ottawa, human trafficking isn’t on the average person’s radar. It is frequently associated with foreign, impoverished, and developing countries, not with cities where the unemployment rate is 6.3% and the median family income is $102,000 (City of Ottawa, 2016). However, the reality is that human trafficking, sex trafficking specifically, is prevalent in Canada’s capital city. The Ottawa Police Service’s Human Trafficking Unit (OPS HTU) estimates that that there are dozens of sex trafficking victims in hotels across the city; in 2018 alone, OPS HTU dealt with 45 cases of sex trafficking (Ottawa Police Service, 2020). If this number seems low, it is important to remember that owing to the clandestine nature of this crime, accurate estimates of the number of cases are difficult to calculate (Public Safety Canada, 2020).

As a society, Canadians hold a very narrow and antiquated perception of human trafficking — that it typically involves a young woman getting kidnapped by strangers and waking up in a foreign country, shackled in a room. Although this sometimes happens (and it is horrible when it does), human trafficking has evolved rapidly along with our society. Human trafficking can happen in a variety of ways, but fundamentally it is any situation that involves the recruitment, harbouring, or transportation of people into exploitation, through the use of deception, coercion, or violence. Anyone can be a victim, however those particularly at risk are Indigenous women and girls, migrants and new immigrants, LGBTQ2 persons, those living with disabilities, children in the child welfare system, at-risk youth, and people who are socially or economically disadvantaged (Public Safety Canada, 2020).

Unique health-care needs of survivors

For survivors of human trafficking, traditional health-care services are inadequate for many reasons. The busyness and chaos of walk-in clinics and emergency rooms are stressful for those who have experienced personal trauma and neglect. The 15-minute time limit for most appointments is restrictive for survivors and providers alike, as it is challenging to establish a sense of safety for the client and to build the rapport that is needed to work through complex histories. Survivors often lack private insurance, and their health cards may have been lost or taken from them, thereby making coverage for assessment, lab tests, and prescriptions difficult. Furthermore, survivors of human trafficking require a safe, judgment-free space tailored to their unique needs.

Any situation that involves the recruitment, harbouring, or transportation of people into exploitation, through the use of deception, coercion, or violence, is human trafficking.

This gap is what inspired the creation of the H.E.A.L.T.H. (Health Care, Education, Advocacy, and Linkage for Trauma-informed Healing) Clinic. Tara Leach, a primary health care nurse practitioner (PHC-NP) with decades of experience working with vulnerable populations and victims of crime, partnered with an existing experiential human trafficking peer support program called Hope Found to create a clinic tailor-made for survivors of human trafficking. Leach is the only health-care provider on the staff, and she brings to the clinic a nurse’s special ability to see the client as a whole. She practises holistic care and acknowledges how trauma — such as sexual violence, exploitation, and adverse childhood experiences — can negatively affect a person’s health.

As a nurse practitioner, Leach does not need to bill for her time through OHIP. This allows her unrestricted appointment times and to not require that her patients have ID or insurance in order to be seen. Through a grant from Ontario’s Strategy to End Human Trafficking, which is supported through the Ministry of Children, Community and Social Services (MCCSS), she was able to secure funds to open a clinic where essential primary and preventive health care is accessible to those who need it. Leach chose a discreet location in an unmarked office building, with a small waiting room that never contains more than one or two people at a time, in order to give patients privacy and anonymity when seeking care — especially important for those who are actively being trafficked.

Partnerships critical to clinic’s success

A fundamental first step in establishing the clinic was forging partnerships with Ottawa-based services that would enhance the funding that supports individual health care. Services include

  1. access to Ontario's Victim Quick Response Program (VQRP), which provides eligible persons with support for emergency home safety repairs, basic necessities, medically related travel expenses, crime scene clean up, etc., and;
  2. peer support within the clinic through the Hope Found project, which enables eligible persons to access personal care items, education, safety planning, advocacy, and more. 

The clinic’s vision is informed by lived experience, ensuring that its focus and care delivery remain grounded in a survivor-focused and trauma-informed model.

The clinic is based on a philosophy of judgment-free, trauma-informed care within a patient-centred framework. It is guided by the six core principles of trauma-informed care (Trauma-Informed Care Implementation Resource Center, 2020):

  • Humility and responsiveness: recognizing and addressing biases and stereotypes
  • Empowerment: recognizing, building on, and validating patient strengths with a focus on resilience and the ability to heal
  • Collaboration: acknowledging and levelling the power differences between staff and clients with regard to decision-making
  • Peer support: integrating individuals with shared experiences into our organization
  • Trustworthiness and transparency: decisions are made with consent and transparency in order to build and maintain client–provider trust
  • Safety: ensuring the safety of patient and staff throughout the health-care experience

Trauma-informed care in practice

Prior to starting at H.E.A.L.T.H., I had no real grasp of what trauma-informed care meant or what it might look like. The first time I fully realized the difference between trauma-informed care and traditional care was during a pelvic exam. I noticed that the nurse practitioner was extremely gentle, constantly checking on the patient and informing her of every step before it occurred. I had never seen or heard of a pelvic exam taking that long or being that informative.

At the H.E.A.L.T.H. Clinic, the most important principle is compassionate, non-judgmental, trauma-informed care.

After the exam I asked the NP, “Was that patient a survivor of sexual assault?” and she replied, “It doesn’t matter — that’s just my practice with all patients.” Trauma-informed care not only improves the health-care experience for patients; it also improves patient engagement, adherence to treatment, and health-care outcomes (Trauma-Informed Care Implementation Resource Center, 2020).

The clinic’s clientele is quickly expanding. We no longer deal exclusively with human trafficking survivors, because we have learned that not all survivors identify with this term, despite their personal histories and experience. We now include patients who have experienced coercion, exploitation, and sexual violence.

The H.E.A.L.T.H. Clinic has clearly had a positive impact on our clients’ lives. Many of them had never been followed by a family doctor, and are now able to request adjustments to their medications, deal with chronic health issues, and learn more about their mental health diagnoses. We’ve also been able to refer many clients to substance abuse programs to help them manage their addictions and re-integrate into society in a safe and productive way.

Some of our clients’ most prevalent needs include STI testing, pregnancy testing, medical abortions, emergency contraception, contraception counselling, and on-site dispensing of contraception of choice. Many of the young people who come through our clinic are unaware of the dangers of unprotected sex and have never had the means to protect themselves.

Mental health issues a concern

Another large portion of our work is dedicated to diagnosing, treating, and managing mental health issues. Many patients come to us with undiagnosed PTSD, anxiety, depression, substance use disorders and ADD (to name a few), and they need help finding the right medication and coping mechanisms. Many have a long history of physical and emotional abuse and neglect, and they require extended time devoted to them — which we are happy to provide.

At the H.E.A.L.T.H. Clinic, the most important principle is compassionate, non-judgmental, trauma-informed care. We don’t penalize people for missed appointments, we don’t force clients into treatment, and we try to help them on their own terms.

Working at the clinic has taught me that survivors of human trafficking have a special set of needs, that no two people are alike, and how to be compassionate when dealing with experiences I could never imagine.

The most important thing I’ve learned? That the best care starts from a place of compassion, understanding, and kindness — regardless of the patient’s past.

References

City of Ottawa. (2016). Statistics.

Ottawa Police Service. (2020). Human trafficking

Public Safety Canada. (2020). Human Trafficking.

Trauma-Informed Care Implementation Resource Center. (2020). What is trauma-informed care?

Asmaa Mabrouk (3rd year BScN student, University of Ottawa) is a strong advocate of trauma-informed care, and hopes to dedicate her career to empowering and supporting survivors of interpersonal traumas. Asmaa sits on the student council of the nursing faculty at the University of Ottawa, is the Official Delegate for the University of Ottawa within the Canadian Nursing Students’ Association (CNSA), recently was the co-director of the CNSA’s provincial Ontario Regional Mental Health Advocacy conference and is currently working on research related to the transition of new graduate nurses into critical care.

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